Nokea
The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?
- A. Fatigue related to altered metabolic processes
- B. Altered nutrition: less than body requirements related to anorexia
- C. Risk for infection related to altered immunologic response
- D. Body image disturbance related to weight loss and anorexia
Correct Answer: C
Rationale: HSCT obliterates marrow, tanking immunity risk for infection soars as neutrophils vanish, making it the top nursing diagnosis pre-transplant. Sepsis can kill fast in this window, unlike fatigue or nutrition issues, which matter but aren't immediate threats. Body image might nag later with hair loss or weight shifts, but infection's the killer to watch. Nurses lock in on this, driving strict isolation and monitoring, knowing a stray germ could derail everything in oncology's high-stakes transplant game.
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The client is admitted for heart failure and has edema, neck vein distension, and ascites. What is the most accurate way to monitor fluid gain or loss in this client?
- A. Auscultate the lungs for crackles or wheezing
- B. Weigh the client daily at the same time with the same scale
- C. Check for pitting edema in the dependent body parts
- D. Assess skin turgor and the condition of mucus membranes
Correct Answer: B
Rationale: Heart failure's fluid dance edema, JVD, ascites needs precise tracking. Daily weights, same time, same scale, catch 1 kg shifts (1 L fluid), the gold standard for gain or loss, outpacing lung sounds' subjectivity. Edema checks or turgor gauge trends, less exact. Nurses weigh in, ensuring diuretic tweaks hit the mark, a reliable ruler in this swollen saga.
A client is receiving treatment for the diagnosis of hemophilia A. Which of the following is the most appropriate to include in the assessment of this client?
- A. Cranial nerves
- B. Appetite
- C. Joint pain and bruising
- D. Urine output
Correct Answer: C
Rationale: Hemophilia A, a factor VIII deficiency, impairs clotting joint pain and bruising from hemarthrosis and bleeds are hallmark signs, demanding assessment to gauge bleeding severity and guide factor replacement. Cranial nerves check neurologic status, irrelevant unless bleeds hit the brain. Appetite or urine output offers general insight, not hemophilia-specific. Nurses zero in on joints and skin, tracking this genetic disorder's impact, critical for managing acute episodes and preventing long-term damage in this bleeding-prone client.
The definition of Chronic Heart Failure is:
- A. Failure of the heart to adequately pump blood to the body.
- B. Long-term inability of the heart to meet metabolic demands required to maintain homeostasis.
- C. Prolonged enlargement of the left ventricle impacting on the contractility of the muscle.
- D. Long term fluid build-up, causing increase in blood volume and reducing the ability of the heart to maintain blood flow.
Correct Answer: B
Rationale: Chronic heart failure (CHF) is a syndrome, not a singular defect. Failure to pump adequately describes acute failure but lacks chronicity's scope. CHF is the heart's prolonged inability to meet metabolic demands for oxygen and nutrients, disrupting homeostasis per Farrell (2017) encompassing systolic (reduced ejection) and diastolic (impaired filling) dysfunction. Left ventricular enlargement may occur (e.g., dilated cardiomyopathy), but it's a cause or result, not the definition; contractility varies. Fluid buildup (congestion) is a feature, not the essence blood volume rises secondary to neurohormonal activation (e.g., renin-angiotensin system), not as the primary failure. The metabolic demand focus captures CHF's systemic impact fatigue, edema, dyspnea reflecting chronic adaptation failure over structural or fluid-centric descriptions.
Which of the following statements is INCORRECT concerning gestational diabetes?
- A. Most commonly developed in the first trimester of pregnancy
- B. Affects 8% of pregnant women
- C. Maternal blood glucose levels will return to normal shortly after birth
- D. There is a high risk of developing type 2 diabetes by the mother within 20 years
Correct Answer: A
Rationale: Gestational diabetes hits late second or third trimester, not first insulin resistance peaks then, a pregnancy twist. Eight percent's close, glucose norms post-birth, type 2 risk looms 20 years fits. Nurses catch this timing, a chronic precursor's true window.
Patients on insulin therapy should receive essential education on the following EXCEPT:
- A. Insulin injection technique
- B. Stopping all oral hypoglycaemic agents
- C. Recognition and self-management of hypoglycaemia
- D. Sick day management
Correct Answer: B
Rationale: Insulin therapy education for diabetes patients covers injection technique, hypoglycemia recognition and management, sick day rules, and safe driving, per diabetes care standards. However, stopping all oral hypoglycemic agents isn't universally essential many patients continue agents like metformin or SGLT-2 inhibitors alongside insulin for synergistic effects, depending on glycemic control needs. Assuming cessation oversimplifies treatment plans, potentially reducing efficacy. Education must tailor to individual regimens, not mandate stopping orals, making this the exception. Physicians ensure comprehensive teaching to enhance adherence and safety, critical in chronic disease management.